Functional morphological alterations of human blood platelets induced by oxidized low density lipoprotein

Oxidised Low-Density Lipoprotein-Induced Platelet Hyperactivity—Receptors and Signalling Mechanisms

Dyslipidaemia leads to proatherogenic oxidative lipid stress that promotes vascular inflammation and thrombosis, the pathologies that underpin myocardial infarction, stroke, and deep vein thrombosis. These prothrombotic states are driven, at least in part, by platelet hyperactivity, and they are concurrent with the appearancxe of oxidatively modified low-density lipoproteins (LDL) in the circulation. Modified LDL are heterogenous in nature but, in a general sense, constitute a prototype circulating transporter for a plethora of oxidised lipid epitopes that act as danger-associated molecular patterns. It is well-established that oxidatively modified LDL promote platelet activation and arterial thrombosis through a number of constitutively expressed scavenger receptors, which transduce atherogenic lipid stress to a complex array of proactivatory signalling pathways in the platelets. Stimulation of these signalling events underlie the ability of modified LDL to induce platelet activation and blunt platelet inhibitory pathways, as well as promote platelet-mediated coagulation. Accumulating evidence from patients at risk of arterial thrombosis and experimental animal models of disease suggest that oxidised LDL represents a tangible link between the dyslipidaemic environment and increased platelet activation. The aim of this review is to summarise recent advances in our understanding of the pro-thrombotic signalling events induced in platelets by modified LDL ligation, describe the contribution of individual platelet scavenger receptors, and highlight potential future challenges of targeting these pathways.

Use of lipidomics for analyzing glycerolipid and cholesteryl ester oxidation by gas chromatography, HPLC, and on-line MS

Various analytical techniques have been adopted for the isolation and identification of the oxolipids and for determining their functionality. Gas chromatography in combination with mass spectrometry (MS) has been specifically utilized in analysis of isoprostanes and other low molecular weight oxolipids, although it requires derivatization of the solutes. In contrast, liquid chromatography (LC) in combination with on-line MS has proven to be well suited for analysis of intact oxolipids without (or minimal) derivatization. LC-MS has also been helpful for the identification of lipidomic changes resulting from covalent binding of lipid ester core aldehydes to amino lipids, amino acids, peptides, and proteins. This chapter reviews the use of the above techniques for lipidomic analysis of the autoxidation products of cholesteryl esters and glycerolipids as practiced in the authors' laboratories.

Plasma very-low-density lipoprotein, low-density lipoprotein, and high-density lipoprotein oxidative modification induces procoagulant profiles in endogenous hypertriglyceridemia

This study was to investigate whether oxidatively modified lipoproteins were associated with changes of pro- and anticoagulant profiles in hypertriglyceridemic subjects. Plasma VLDL, LDL, and HDL were isolated with the one-step density gradient ultracentrifugation method. The oxidation of the lipoproteins was identified. Prothrombin time (PT) and activated partial thrombplastin time (APTT), tissue plasminogen activator and plasminogen activator inhibitor-1, and platelet aggregation rate were determined with a reaction system consisting of mixed fresh normal plasma, in endogenous hypertriglyceridemic (HTG) patients, in in vitro modified lipoproteins from a normolipidemic donor, and in experimental rats. The results indicated that oxVLDL, oxLDL, and oxHDL occurred in the plasma of HTG patients. Compared with the control group, PT and APTT, incubated with plasma VLDL, LDL, or HDL from HTG patients, respectively, were significantly reduced, while platelet maximal aggregation rates were significantly higher (P < 0.05-0.01). Similar procoagulant profiles were observed in in vitro modified lipoprotein components and in rats with intrinsic hypertriglyceridemia as well. These results support our previous finding that LDL, VLDL, and HDL were all oxidatively modified in vivo in the subjects with HTG, and suggest that procoagulation state may result from the abnormal plasma lipoprotein oxidative modification in vivo.

The influence of platelet-smooth muscle cell interaction on the oxidative modification of low-density lipoprotein

OBJECTIVE

In view of the recognized association between thrombosis and atherosclerosis, it is hypothesized that exposure of arterial smooth muscle cells (SMC) to thrombogenic agents such as platelets and thrombin will alter the oxidation of low-density lipoprotein (LDL) and that this effect may be diminished by thrombin inhibition.

METHODS

Quiescent human aortic SMC in culture were exposed to LDL (40 microg protein/ml) alone or with washed human platelets (5 x 10(6)/ml), thrombin (40 units/ml), or a combination of these agents for 48 h. The media were removed, and both media and cell lysate fractions were assayed for malondialdehyde (MDA) content as an index of oxidation. Isolated platelets exposed to LDL and thrombin were studied in a similar manner to determine their individual oxidative activity. Finally, SMC and platelets were incubated with LDL and varying concentrations of thrombin (10-80 units/ml), both alone and in the presence of the thrombin inhibitors hirudin (u/u), and heparin (u/u), and MDA was measured.

RESULTS

SMC and platelets each demonstrated an ability to oxidize LDL, increasing MDA concentrations by 1.8- (P < 0.05) and 4- (P < 0.01) fold, respectively, compared to lipid-free media. Both platelets (P < 0.05) and thrombin (P < 0.001) enhanced the oxidation of LDL by SMC, while a combination of these two agents resulted in an additive effect (P < 0.001). The SMC lysate fraction showed an increase in oxidative products following exposure to platelets (P < 0.01) but not thrombin, suggesting that platelets stimulated uptake of the oxidized lipid by the SMC. Isolated platelets responded to thrombin with an increase in MDA within the media (P < 0.001). Smooth muscle cells exposed to thrombin also showed a dose-dependent increase in LDL oxidation (P < 0.01). This effect was not altered by hirudin, but was significantly inhibited by heparin (P < 0.05).

CONCLUSIONS

These results indicate that the oxidative potential of SMC and platelets is enhanced by their coincubation and by their concurrent exposure to thrombin. Heparin appears to block thrombin-stimulated oxidation. This interaction could be relevant to the dynamic interaction between atherosclerosis and thrombogenesis.

Activation-dependent surface expression of LOX-1 in human platelets

Lectin-like oxidized LDL receptor-1 (LOX-1) was initially identified as an oxidized LDL receptor in aortic endothelial cells. Here we identified LOX-1 mRNA and protein in human platelets in addition to recent findings on the expression in macrophages and smooth muscle cells. The presence of LOX-1 was further confirmed in the megakaryocytic cell lines. Flow cytometric analyses revealed that LOX-1 was exposed on the surface of platelets in an activation-dependent manner. Consistently, the activation-dependent binding of OxLDL to platelets was mostly inhibited by anti-LOX-1 antibody. Immunohistochemistry of the atherosclerotic plaque from a patient with unstable angina pectoris (UAP) revealed accumulation of LOX-1 protein at the site of thrombus. As LOX-1 recognizes and binds activated platelets, exposure of LOX-1 on activated platelets surface might assist thrombosis formation.

Oxidized low-density lipoprotein (LDL) enhances thromboxane A(2) synthesis by platelets, but lysolecithin as a product of LDL oxidation has an inhibitory effect

Oxidation of low-density lipoprotein (LDL) by copper sulfate led to a significant increase in lysophosphatidylcholine (lyso PC) at the expense of phosphatidylcholine. Incubation of different concentrations of oxidized LDL (oxLDL) (32-650 microg protein/ml) with platelets for 1 h at 37 degrees C increased lyso PC content. The increase was dependent on oxLDL concentration. Incubation of platelets with various concentrations of lyso PC in solution for 5 or 15 min showed that lyso PC percentage was increased in the platelet membrane and the increase was dose dependent. Platelets incubated with various concentrations of lyso PC (2-100 microM) for 5 or 15 min and then triggered with thrombin also showed a significant decrease of thromboxane A(2) (TXA(2)) release as lyso PC concentration reached 10 microM or 6 microM, respectively. The decrease of TXA(2) release was more significant as lyso PC concentration was increased. The present study showed that this inhibition of TXA(2) release by lyso PC was due to 1) inhibition of phospholipase A(2) and the decrease of free arachidonic acid liberation from platelet phospholipid and 2) inhibition of cyclooxygenase. These inhibitory effects of lyso PC were discussed in relation to its effect on membrane fluidity. Lyso PC at concentrations of 30, 50, and 100 microM caused a sudden drop in TXA(2) release and a sudden increase of lactic dehydrogenase loss from the platelets due to their lysis and inhibition of cyclooxygenase enzyme. The present study shows that oxLDL contains high levels of lyso PC that are transferable to the platelets and can weaken their responsiveness to thrombin and decrease TXA(2) release. In our previous study, we found that oxLDL also contained high levels of oxysterols and thiobarbituric acid reactive substances (TBARS), which enhanced platelet reactivity to thrombin and increased TXA(2) release. We conclude that the net effect of oxLDL on platelets will depend on its degree of oxidation and the ratio between oxysterols plus TBARS/lyso PC. Variations in this ratio may explain some of the contradictions cited in the literature concerning the effect of oxLDL on platelet activation.

Stimulating effect of biologically modified low density lipoproteins on ADP-induced aggregation of washed platelets persists in absence of specific binding

Oxidized low density lipoproteins are closely associated with atherosclerosis and also might be directly involved in thrombosis because they have been shown to mediate a stimulating effect on human platelets. In this work, we used biologically modified low density lipoproteins (i.e., low density lipoproteins sufficiently oxidized to show specificity for the macrophage scavenger receptor system) to examine if specific binding of the oxidized apolipoprotein moiety to the platelet surface is a prerequisite for the platelet-stimulating effects reported by other authors. We find that biologically modified low density lipoproteins show specific binding to human platelets (K(d)=5.83+/-0.4 microg/mL, 3850+/-620 sites/platelet) and strongly augment both ADP- and thrombin-induced aggregation of washed platelets. Maleylated albumin, an antagonist of oxidized low density lipoproteins binding to all currently classified scavenger receptors, is able to reduce platelet oxidized low density lipoproteins binding to background levels. Nevertheless, maleylated albumin is not able to exert any kind of normalizing effect on the augmented ADP-induced aggregation response observed in the presence of biologically modified low density lipoproteins. From these data, we conclude that specific binding of oxidatively modified apolipoprotein B to the platelet surface is not essential to the process of platelet stimulation. Therefore, we conclude that these stimulating effects may be mediated by unidentified compounds formed in the lipid phase of the lipoproteins.

Effects of hypochlorite-modified low-density and high-density lipoproteins on intracellular Ca2+ and plasma membrane Ca(2+)-ATPase activity of human platelets

The presence of hypochlorite-modified lipoproteins in atherosclerotic lesions suggests that HOCl, a naturally occurring oxidant formed by the myeloperoxidase-catalyzed reaction of H2O2 and Cl-, is a candidate for generation of modified lipoproteins in vivo. We have previously demonstrated that Cu(2+)-oxidized LDL inhibits platelet plasma membrane Ca(2+)-ATPase (PMCA) in isolated membranes and causes an increase in cytosolic Ca2+ in resting whole platelets. However, Cu(2+)-oxidized LDL may not be identical in structure and function to the physiologically modified lipoprotein. Since platelet function may be affected by native and modified lipoproteins, the effect of HOCl-modified LDL and HDL3 on platelet PMCA and on the free intracellular Ca2+ concentration ([Ca2+]i) of whole platelets has been investigated. We demonstrate that in contrast to Cu(2+)-oxidized LDL, HOCl-modified LDL and HDL3 stimulate platelet PMCA activity in isolated membranes and that this effect results in a decrease of [Ca2+]i in vivo. Thus, HOCl-oxidation produces modified lipoproteins with the potential for altering platelet function and with properties different from those of the Cu(2+)-oxidized counterparts.

Oxidized low-density lipoprotein inhibits the binding of monoclonal antibody to platelet glycoprotein IIB-IIIA

Previous studies have shown that oxidized low-density lipoprotein (LDL) induces platelet activation more effectively than native LDL. To achieve a better understanding of the mechanism underlying the activation of human platelets by oxidized LDL, the present study relates the effect of oxidized LDL to changes of binding characteristics for glycoprotein (GP) IIb-IIIa. Washed human platelets were treated by monoclonal antibody against GP IIb-IIIa, and the ligand-receptor complexes were revealed by immunocytochemical techniques on the ultrastructural level. The localization of the antiglycoprotein IIb-IIIa was time-dependent. After binding to the platelet surface membrane and open canalicular system, the surface-membrane labeling decreased during longer incubation periods. Preincubation with oxidized LDL inhibited the binding of antiglycoprotein IIb-IIIa. Our findings suggest that GP IIb-IIIa acts as a receptor for oxidized LDL. The binding of oxidized LDL to the GP IIb-IIIa might be the first step in platelet activation by plasma lipoproteins.

Native and oxidized low density lipoproteins enhance platelet aggregation in whole blood

The effects of native and oxidized low density lipoproteins on platelet aggregability remain controversial despite numerous studies. In the current investigation, effects of native, minimally and extensively copper-modified low-density lipoproteins on aggregation responses to ADP and collagen in platelet-rich plasma, washed platelets, and whole blood were studied. Preincubation with native and oxidized low-density lipoproteins (1.5-23.2 malondialdehyde equivalents [MDAeq]/mg low density lipoprotein) did not modify aggregability in platelet-rich plasma or washed platelets but increased aggregation markedly in whole blood (40-58%, p<0.01). In whole blood, the increase in response to ADP was not affected by the degree of low-density lipoprotein oxidation. This comprehensive investigation of low density lipoprotein effects on platelet aggregation therefore has demonstrated that low density lipoproteins indirectly increase platelet aggregability in whole blood, but not in platelet-rich plasma and washed platelets, presumably via an interaction between platelets and other formed elements of blood.

High-density lipoprotein: multipotent effects on cells of the vasculature

The epidemiological evidence showing a strong inverse correlation between the level of plasma high-density lipoprotein (HDL) and the incidence of heart disease suggests that HDL has a protective effect against cardiovascular disease. The mechanism of this protective effect has been the raison d'etre for much research. The ability of HDL to mediate cholesterol efflux from peripheral tissues has been used to explain the cardioprotective effect of HDL. However, there is little direct evidence to suggest that in subjects with low plasma levels of HDL the rate of cholesterol efflux from peripheral tissues is significantly reduced. This observation suggested that HDL may be mediating its protective effect through other mechanisms. This review provides an account of the burgeoning evidence that HDL has many effects on cellular processes, in addition to the effects on cholesterol efflux, and will illustrate the multipotency of this lipoprotein.

Vitamin E (alpha-tocopherol) does not inhibit platelet stimulation by oxidized low density lipoprotein in vitro

Platelet-rich plasma were treated with increasing concentrations of vitamin E (alpha-tocopherol). Washed platelets were exposed to oxidized low density lipoprotein (LDL) and examined by aggregometry and electron microscopy. The treatment of washed platelets by oxidized LDL induced morphological signs of activation like pseudopodia formation and an increase in light transmission. Alpha-tocopherol in a range of 0.001-1.0 mmol had no inhibiting influences on platelet activation by oxidized LDL. These results indicate that the free radical scavenger vitamin E cannot directly inhibit platelet activation by oxidized LDL. It may be supposed that platelet activation by oxidized LDL does not occur in a radical-dependent mechanism.

Oxysterols and TBARS are among the LDL oxidation products which enhance thromboxane A2 synthesis by platelets

In this study, we compared the effects of normal LDL (nLDL) and oxidized LDL (oxLDL) on thromboxane (TXA2) release by platelets triggered by low concentration of thrombin, and we determined which component of oxLDL is responsible for that activation. After oxidation of LDL with copper sulfate, the small molecular weight fraction (< 10 kDa) which was high in TBARS was removed; using Amicon Centriprep-10 concentrator membrane. More than 67% of TBARS in the oxLDL preparation was found in solution while the remaining was covalently attached to the oxLDL particles. OxLDL contained significantly higher levels of oxysterols and TBARS than the nLDL. Platelets preincubated with low concentrations of oxLDL (33-132 micrograms protein/mL) produced significantly higher TXA2 than platelets preincubated with equivalent concentrations of nLDL when triggered with thrombin. Platelets treated with oxLDL also contained significantly higher levels of oxysterols than platelets treated with nLDL. Platelets preincubated with pure cholestanetriol (10 micrograms/mL) contained a high level of cholestanetriol in the membrane, and TXA2 release was significantly increased in these platelets compared to the control platelets. The TBARS in solution also was very potent in enhancing TXA2 release by thrombin-treated platelets. These results indicate that oxysterols and the free TBARS either in solution or covalently attached to the oxLDL particles are partly responsible for the stimulatory effect of oxLDL on TXA2 release by platelets. The present study also showed that this enhancement of TXA2 release was due to activation of phospholipase A2 and to the increase of arachidonic acid liberation from the platelet phospholipids.

Oxidized LDL damages endothelial cell monolayer and promotes thrombocyte adhesion

The influence of oxidized low density lipoprotein (LDL) on a human endothelial cell monolayer was examined. The resulting contraction of the oxidized LDL-damaged endothelial cells lets intercellular spaces become enlarged and therefore visible via light microscopy. Electron microscopy reveals that the structural damage facilitates thrombocyte adhesion and formation of microthrombi. Oxidized LDL appears to play a pivotal role in initiating and deteriorating thromboembolic complications.

Influence of purified apoprotein E on platelet activation induced by serotonin

Serotonin induces platelet activation. Purified apoprotein E of 300 micrograms/ml prevented morphological alterations of blood platelets stimulated with serotonin (5 microM). Lower concentrated apoprotein E showed no such clear effects. These findings suggest that apoprotein E may liter atherosclerosis by suppressing agonist-induced platelet activation.

Oxidized low density lipoprotein inhibits platelet plasma membrane Ca(2+)-ATPase

Oxidized low density lipoprotein (LDL) has been shown to enhance platelet activation. Since platelet activation is accompanied by an increase in cytosolic calcium, the effects of oxidized LDL on plasma membrane Ca(2+)-ATPase, plasma membrane fluidity and cytoplasmic calcium were studied in human platelets and purified platelet plasma membranes. Our results demonstrate that oxidized LDL, but not native LDL, inhibits the activity of Ca(2+)-ATPase in purified platelet plasma membranes (P < 0.01). Addition of the free radical scavenger alpha-tocopherol had no effect on the ability of oxidized LDL to inhibit the Ca(2+)-ATPase. An increased cytoplasmic calcium level in whole platelets was induced by oxidized LDL (P < 0.01), indicating that the plasma membrane Ca(2+)-extrusion pump may also be inhibited in vivo by oxidized LDL, although other mechanisms for the increase in cytoplasmic calcium are possible. Since no change in membrane fluidity was observed in platelet plasma membranes exposed to oxidized or native LDL as estimated by steady state trimethylammonium diphenylhexatriene (TMA-DPH) anisotropy, oxidized LDL does not affect the Ca(2+)-ATPase by grossly changing the membrane environment. The present results suggest that exposure of platelets to oxidized LDL causes inhibition of the plasma membrane Ca(2+)-ATPase which contributes to the observed increase in cytoplasmic calcium and increased sensitivity to agonists.

High-density lipoprotein fails to inhibit serotonin-induced activation of blood platelets

High-density lipoprotein (HDL) of 100-400 micrograms/ml did not prevent morphological alterations of human blood platelets treated with serotonin (1-5 microM). Highly concentrated HDL (1,200 micrograms/ml) appeared to activate platelets in vitro. These findings indicate that whole HDL may not inhibit agonist-induced platelet activation.

Mildly oxidized LDL induces platelet aggregation through activation of phospholipase A2

Native LDL and LDL oxidized under various conditions were compared in terms of their ability to activate platelets. Native LDL did not induce platelet shape change or aggregation, even at high concentrations (2 mg protein/mL). LDL was mildly oxidized with either CuSO4 (mox-LDL) or 3-(N-morpholino)sydnonimine (SIN-1-LDL). Analysis of mox-LDL and SIN-1-LDL showed a small increase of dienes (E234nm from 0.28 +/- 0.04 to 0.55 +/- 0.09, mean +/- SD) and thiobarbituric acid-reactive substance (from 0 to 10.6 +/- 1.5 nmol/mg, mean +/- SEM), no change in apo B electrophoretic mobility, and a minor (12% to 30%) decrease in polyunsaturated fatty acid content. Interestingly, this small oxidative modification of LDL dramatically changed its effect on platelets. Irreversible aggregation and secretion were induced by a threshold concentration of 0.4 mg protein/mL. In contrast, LDL thoroughly oxidized with CuSO4 (ox-LDL) did not aggregate platelets. Although mox-LDL was depleted in antioxidants (alpha- and gamma-tocopherol, alpha- and beta-carotene, and other carotenoids), incubation of mox-LDL with exogenous alpha-tocopherol did not reverse its ability to induce platelet aggregation and secretion. Preincubation of platelets with the cyclooxygenase inhibitor aspirin or the phospholipase A2 inhibitors trifluoperazine, quinacrine, 4-bromophenacyl bromide, and propranolol completely prevented platelet aggregation and secretion caused by mox-LDL or SIN-1-LDL. These results indicate that mildly oxidized LDL activates platelets through a phospholipase A2/cyclooxygenase-dependent pathway. The complete inhibition of mox-LDL-induced platelet aggregation by aspirin could contribute to its beneficial effect in cardiovascular disease.

Adhesion of washed blood platelets in vitro is advanced, accelerated, and enlarged by oxidized low-density lipoprotein

In order to study the influence of oxidized low-density lipoprotein (Ox-LDL) on platelet functional morphology at an early activation stage, washed human blood platelets were stimulated by 100 micrograms/ml Ox-LDL at 37 degrees C. The settling and spreading process of stimulated and unstimulated platelets on Formvar-coated glass was observed for approximately 20 min by reflection contrast microscopy (RCM) and quantified by image analysis. Each group consisted of at least 250 platelets. The results show that incubation with Ox-LDL causes platelet shape change and pseudopodia formation. The sedimentation of stimulated platelets precedes that of unstimulated platelets by approximately 3 min. The increase of the total adhesion area of all Ox-LDL treated platelets is significantly accelerated in comparison to normal platelets (20.45 microns2/min vs. 15.45 microns2/min; P < 0.01). The mean total adhesion area of Ox-LDL-treated platelets was generally larger than that of untreated platelets (189.7 microns2 vs. 144.7 microns2; P < 0.01). The disappearance of intracellular granules after platelet activation, observed by RCM, is supported by transmission electron microscopy. Our results suggest that Ox-LDL activates platelets and advances and accelerates their adhesion and thereby may contribute to pathological thrombosis and arteriosclerosis.

Evaluation on blood platelets by the image analysis system VIDAS 2.5

This paper introduces a program written on the image analysis system VIDAS 2.5. It enables the automatic quantification of high numbers of adhesion areas of vital human platelets, thus allowing statistical analysis. These adhesion areas were observed by reflection contrast microscopy (RCM), which generates images of an intense contrast and serves as a prerequisite for an evaluation by image analysis. However, RCM-photographs of the observed platelets have highly varying mean greyvalues and greyranges. These common problems for self-operating identification are excluded by two procedures within the program: 1. calibration of the scanning process for an optimal use of the available greyvalues provided by the negative, camera, and the image analysis system; and 2. relation of the threshold for discrimination of adhesion areas to the statistic parameters of the histogram within each individual digitized image. Images processed according to these prerequisites were transferred to the VIDAS implemented routines for identification and measurement of areas. Thus, image analysis combined with RCM offers a tool for basic and clinical platelet research, which is shown by an example of stimulation and inhibited stimulation of platelet activation.

Endothelial cells injured by oxidized low density lipoprotein

Cultured endothelial cells from bovine aorta were exposed to oxidized low density lipoprotein and examined by electron microscopy. The endothelial cells contracted slightly and the intercellular junctions became unclear. Some osmiophilic material increased in the cytoplasm. The oxidized low density lipoprotein appears to injure endothelial cells and thereby plays a causative role in atherogenesis and thrombogenesis.

Oxidized LDL induces serotonin release from blood platelets

Oxidized low-density lipoprotein (LDL) induces a release of serotonin from morphologically resting platelets and shape changed platelets. This suggests that oxidized LDL, a newly reported weak agonist, contributes to atherogenesis and thrombogenesis by stimulating platelets.

Decreased adhesion of oxidized LDL-stimulated platelets caused by cytochalasin D

The adhesion of human blood platelets is studied with an in vitro model using reflection contrast microscopy and an image analysis system. The adhesive feature is promoted by oxidatively modified low density lipoprotein, which also induces functional morphological changes of platelets. However, when washed platelets are pretreated with 0.05 mM cytochalasin D, oxidized low density lipoprotein (100 micrograms/ml) causes a slower increase of the adhesion area (11.6 microns 2/min) compared to untreated platelets (15.7 microns 2/min) or platelets treated by oxidized low density lipoprotein alone (20.5 microns 2/min, P < 0.01). These results are supported by light transmission analysis and by transmission electron microscopy. Our experiments suggest that cytochalasin D inhibits the change of platelets in shape induced by oxidized low density lipoprotein, hinders the adhesion, but does not prevent the adhesion entirely.